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Pharmacotherapy When treating adolescents with coexisting disorders, it is paramount for programs to consider the client's need for appropriate medication. For example, substance use disorder treatment facilities should suspend "nomedication" rules for depressed adolescents who have been prescribed antidepressants. Of course, medication, whether for detoxification or the treatment of psychiatric disorders, must be prescribed and dispensed under the direction of a physician. It is recommended that youths with coexisting disorders receive supplemental counseling regarding their psychiatric medication. Discontinuation of any medication is a decision that should be made only in consultation with a medical doctor. Abrupt discontinuation of certain psychotropic medications can be extremely dangerous. However, if the patient continues to use illicit substances, the medication regimen should be reassessed. The relative risks and benefits of a temporary discontinuation of pharmacotherapy (until abstinence is achieved) should be carefully considered. The use of stimulant medication (for AD/HD) or minor tranquilizers (for anxiety disorders) is still controversial for adolescents with substance use disorders. Some of these medications have significant potential for addiction or abuse. Nonaddictive medications, as well as behavioral and psychotherapeutic interventions, should be considered before medications with the potential for addiction or abuse are prescribed. For cases in which these medicines must be used, regular urine testing for substances of abuse, and/or serological determination of therapeutic drug levels, is usually indicated. Family Factors The risk of adolescent health and behavioral problems, including substance use disorders, rises with lack of parenting skills, high levels of family conflict, and poor bonding between parents and children. Recent national data of adolescent health identified the importance of connectedness to parents and family as a key factor that protects adolescents, in a cross-cutting manner, from many problem behaviors, including substance use (Resnick et al., 1997). When parents have unclear expectations of their children's behavior, apply discipline inconsistently, or fail to reward their children for positive or desirable behavior, their children's risk for substance use disorders increases. Both permissiveness and excessively harsh parenting practices can lay the groundwork for adolescent behavioral problems and substance use disorders (Patterson, 1982). An adolescent's family also provides a crucial background to the child's substance use for reasons both genetic and environmental. Children of parents with substance use disorders are at increased risk of developing substance use disorders themselves compared with children with nonsubstance-abusing parents (Cotton, 1979; McGue et al., 1992; Schuckit, 1987). An assessment of the family's history of substance use will provide some insights into the possible role of genetic factors in the family lineage. Perhaps even more relevant to the adolescent patient's immediate concern is the need to evaluate the family environment for risk and protective factors that pertain to substance use. Salient environmental factors include parental modeling of substance use behaviors, permissive parental attitudes toward substance use, and substance use by siblings (Hawkins and Fitzgibbon, 1993). Clinicians working with adolescents with substance use disorders should consider the degree of stability and commitment in the patient's family in determining the most appropriate treatment type and approach for each individual. Ideally, the family should be involved in all phases of the adolescent's treatment, but in families characterized by extreme instability, conflict, physical or sexual abuse, and/or domestic violence, this may not be possible or even advisable. It is important for providers to remember that "family" may include a broad spectrum of members, such as grandparents, older siblings, and foster parents. Social and Community Factors School life, peer influences, the community, and the media may also exert an influence on the adolescent's risk to initiate and maintain substance use (Newcomb and Bentler, 1989). Understanding their influences on an individual can help a service provider pinpoint areas of intervention relevant to the client's recovery.